safe and reliable transport services for new south wales
Train Door Emergency
Egress and Access and
Emergency Evacuation Procedures
Safety Report
Published by
Independent Transport Safety & Reliability Regulator (ITSRR)
Transport Safety Regulation Division
Issue date: November 2004
Document reference: 02468
Train door emergency egress and access and emergency evacuation procedures
ISBN: 0 9756913 1 7
TRAIN DOOR EMERGENCY
EGRESS AND ACCESS
and
EMERGENCY EVACUATION
PROCEDURES
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
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TABLE OF CONTENTS
1.0
Introduction and objectives........................................................................................4
2.0
Executive summary ....................................................................................................4
3.0
Door access, current policy .......................................................................................7
4.0
Emergency door opening, current policy ..................................................................8
4.1 Current Policy adopted by RailCorp ................................................................8
4.2 Why this policy was adopted ............................................................................8
4.3 Injuries due to passengers opening doors ..........................................................8
4.4 Review of current evacuation procedures ........................................................11
4.5 Emergency Signage ...........................................................................................12
5.0
Comparison with other transport modes .................................................................13
6.0
Lessons learnt from past accidents ...........................................................................14
6.1 International examples ....................................................................................14
6.1.1 NORWAY.................................................................................................14
January 2000: Asta, Norway. ........................................................................ 14
6.1.2 AUSTRIA ................................................................................................14
November 2000: Kaprun, Austria. Kaprun funicular railway........................... 14
6.1.3 KOREA ....................................................................................................15
February 2003: Dae-gu Subway, Korea. .......................................................... 15
6.1.4 United Kingdom .......................................................................................16
September 1997: Southall, UK. ....................................................................... 16
October 1999: Ladbroke Grove Junction, UK. ................................................ 16
6.1.5 USA ..........................................................................................................17
September 1993: Mobile, Alabama, USA. ....................................................... 17
February 1996: Silver Spring, Maryland, USA. ............................................. 17
March 1999: Bourbonnais, Illinois, USA. ...................................................... 18
6.1.6 CANADA.................................................................................................18
November 1994: Riviere-Beaudette, Quebec, Canada...................................... 18
November 1994: Brighton, Ontario, Canada. ................................................. 19
March 1996: North Bay, Ontario, Canada...................................................... 20
September 1997: Biggar, Saskatchewan, Canada. .......................................... 20
6.2 NSW Accidents ..............................................................................................21
July 2000: Linden-Woodford. ......................................................................... 21
October 2000: Kingsgrove................................................................................ 21
July 2002: Hexham. ........................................................................................ 21
August 2002: Bargo-Yerrinbool........................................................................ 22
January 2003: Waterfall. ............................................................................... 22
May 2004: Baan Baa. ..................................................................................... 23
6.3 Findings from Rail Emergency Exercises .......................................................25
6.4 Review findings from past rail accidents. ........................................................26
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
6.4.1 Emergency Procedures ..............................................................................26
6.4.2 Emergency Access .....................................................................................27
6.4.3 Diesel and Electric trains .........................................................................27
7.0
Findings from the Waterfall Commission of Inquiry ..............................................29
7.1 Evidence from Mr Heumiller .........................................................................29
7.2 Evidence from Mr Frankovic ............................................................................29
7.3 Evidence from Mr Johnson ............................................................................30
7.4 Evidence from Mr Lauby ...............................................................................31
8.0
Other reports and associated research .....................................................................32
8.1 Comparison with other operators ...................................................................32
8.2 Research conducted by Professor Galea ..........................................................32
8.3 Research into Emergency Door Release conducted by Interfleet
Technology Ltd. .............................................................................................33
9.0
Review of legislation and standards in some developed countries ............................34
9.1 United Kingdom .............................................................................................34
9.1.1 British Standard BS 6853:1999.................................................................34
9.1.2 Power Operated External Doors on Passenger Carrying Rail
Vehicles GM/RT 2473 .............................................................................35
9.1.3 Emergency and Safety Equipment and Signs on Rail Vehicles.
GM/RT 2177 ...........................................................................................35
9.1.4 ATOC Vehicles Standard: AV/ST9002: Vehicle Interiors Design for
Evacuation and Fire Safety. .......................................................................35
9.2 CANADA ......................................................................................................36
9.2.1 Railway Passenger Car Inspection and Safety Rules .................................36
9.2.2. Railway Passenger Handling Safety Rules ...............................................36
9.3 USA ................................................................................................................37
9.3.1 Federal Railroad Administration (FRA) Code of Federal
Regulations – 49 CFR Chapter 11 (10-1-03 Edition) ..............................37
9.3.2 Standard for Emergency Signage for Egress/Access of
Passenger Rail Equipment.........................................................................39
9.3.3 Standard for Emergency Evacuation Units for Passenger Rail Cars. ........39
10.0 Report on fire risk assessment ..................................................................................40
11.0 Summary..................................................................................................................41
12.0 Recommendations ...................................................................................................43
13.0 References ................................................................................................................46
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1.0 INTRODUCTION AND OBJECTIVES
The purpose of this paper is to consider if a standard should be created in NSW covering
train emergency evacuation procedures, door egress and access and associated equipment.
The purpose of this standard would be to improve the emergency response capability of
rail operators within the state. This standard would apply to all passenger carrying trains
operating within NSW. This paper considers whether the new standard should encompass
the ability of passengers to self-evacuate (escape) if the situation should be serious enough to
warrant it and includes a review of the door security policy currently adopted by RailCorp.
2.0 EXECUTIVE SUMMARY
This project has involved researching various reports covering the subject, reviewing some
of the existing standards and legislation in place in some countries; reviewing accident
reports and the accompanying recommendations involving some of the train accidents that
have occurred within NSW and overseas in the last 10 years. Various reports covering a
comparison between Australia and other developed countries have also been taken into
account.
In Canada, the USA and the UK, recent accidents have led to more prescriptive legislation
and/or standards being imposed regarding this issue. These mandatory standards are
imposed by the government bodies responsible for rail safety in each of these countries. In
Australia, no such standards have been imposed by State Government rail regulators.
These countries had no policy similar to that of RailCorp where doors were locked and
passengers were unable to open them in an emergency. Rather, trains operating in these
countries had internal door release mechanisms and in some cases emergency windows
as well. However a continuous theme in the accident report recommendations included
calls for improved means of passenger escape mechanisms. This included better signage
and availability of information for the passengers. Easier access to emergency levers and
handles, better lighting to illuminate escape routes, are other repeated themes. Many
reports are critical of crew actions following emergencies that indicate a lack of training
and preparedness in emergency procedures.
The current RailCorp door security policy is reliant upon the train crew to conduct and
control the evacuation of passengers. The doors are locked before departure of the train
from the platform and the passengers are unable to override this mechanism and open
doors from the inside. In the event of the loss of power, the doors will “fail” in the locked
position. The passengers are reliant upon the crew to facilitate their evacuation or for doors
to be opened externally by the emergency services or rail personnel.
The Waterfall accident that occurred in 2003 was an example of an accident in which the
train crew became incapacitated. This was an accident which occurred in an area bordering
a national park away from main roads and the highway. It was accessible only by dirt roads
and behind a locked gate. It took some time for StateRail (approximately 40 minutes) to
identify an accident had occurred and to locate the position of the train.
This accident highlights that there is the potential for an accident to occur where the
crew are unavailable to conduct an evacuation, power is lost, the doors are locked, people
are injured, mobile phones work only intermittently, the train is two kilometres from the
nearest station in a relatively isolated area and the emergency services are having trouble
finding the location.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
The research conducted for this project highlights that:
a) Trains operating within the USA, the UK and Canada all have doors that permit
passengers to open and self evacuate in the case of an extreme emergency. In some
cases emergency window exits are also provided;
b) All these countries have legislation and/or standards covering the requirements for
emergency exits and the availability of information to the public;
c) The incidence of vandals tampering with emergency door opening devices in these
countries is reportedly not significant, even though these are countries that suffer
other forms of vandalism to their trains;
d) Many of the accident reports studied have a recurring theme amongst the safety
recommendations, including the need for better signage and the provision of
information to passengers on how to operate emergency exits, for the maintenance
of emergency exits and for better emergency lighting and public address systems;
e) Another reoccurring theme is the deficiency of emergency procedures training
provided to train crew;
f ) According to an independent report prepared by Det Norske Veritas Consultancy
Services, the rate of frequency of fires occurring on the StateRail network is twice
that of the rate that occurs on the rail network in the UK;
g) RailCorp procedures are dependent upon the train crew unlocking the doors and
controlling the evacuation;
h) However the Waterfall accident was an example of an emergency where the crew
were incapacitated and unable to perform that role.
From all the documentation and expertise available, it is the recommendation of this paper
that the current door security policy adopted by RailCorp should be amended and that
passengers should have the ability to open the train doors in an extreme emergency and self
evacuate (escape).
The inherent dangers associated with this are recognised. It is important to stress that the
preferred means of train evacuation following an emergency would be (as it is currently)
for the driver to stop at the closest station, open doors onto the platform and for the train
crew to control passenger egress from the train. Passengers opening doors themselves and
self evacuating is a last resort that would only occur in the most extreme situation where to
remain on the train could pose a greater danger than that posed by exiting the train.
It is also recognised that the provision of an internal emergency door release mechanism
could result in doors being opened accidentally or as an act of vandalism. Steps should and
can be taken to minimise such occurrences and suggestions are included in this paper as to
how this could be accomplished. However this area does need further study to see how it is
best achieved. It is worth noting that in the USA, Canada and the UK, countries that are
also subject to acts of vandalism on their trains, there are few reports of doors being opened
in such circumstances.
Lord Cullen conducted an inquiry into the Ladbroke Grove Junction accident in the UK.
In his report he states that:
“Where it is necessary for passengers to leave a train after a crash or other emergency, they
should do so, if circumstances permit, under the supervision of train staff in a controlled
or organised manner… There may be cases where there is no organised evacuation and
where the apparent hazards inherent in remaining on board are substantial……..
This is one of the lessons of Ladbroke Grove. In these circumstances provision has to be
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
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made to enable individual passengers to escape on their own initiative. The means of
evacuation and escape must be readily identifiable, available and effective.”
In the Ladbroke Grove inquiry the issue of vandalism was raised. It was agreed that measures
should be included to minimise the damage done by vandalism; however it was stated in the
report that “vandalism should not be an excuse for a lack of passenger emergency safety features”.
Professor Galea, from the University of Greenwich, who was called as an expert witness to
the inquiry, stated that vandalism was really a separate issue from passenger safety, and he
stated that:
“If the risk assessment case shows that the suggested recommendation is of benefit, of net
benefit to passenger safety, then the issue of vandalism should be addressed as an issue of
vandalism and not as an issue potentially of passenger safety”.
Generally Lord Cullen agreed with this remark; however he believed that it was unrealistic
to ignore the risk of vandalism.
This is also the case with this report. The recommendation is that the doors should be
provided with an internal door opening device that permits passengers to escape in a serious
situation. However physical, mechanical and psychological (eg fines and penalties) defences
should all be explored to deter misuse of any safety device.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
3.0 DOOR ACCESS, CURRENT POLICY
Currently doors can be opened from the outside. Doors can be opened via the Emergency
Door Release (EDR) button or lever. All these buttons or levers are located behind a panel
that is notated EDR. There is a minimum of one of these devices located on the side of each
car, with a second device diagonally opposed on the opposite side of the car. Some cars, for
example the XPT, the Xplorer and the Endeavour cars have a device on every door.
The panel covering the EDR device has no identifying feature to indicate it is a piece of
emergency equipment, there is no colour or striping. The only notation is the lettering
“EDR”.
However this acronym is not familiar to all emergency services personnel. At the Waterfall
accident, emergency services were unaware of this panel and proceeded to attempt to
open doors and break windows using rocks and other such pieces of equipment. There are
examples overseas of accidents where the emergency services were unable to locate door
opening devices to gain quick access to the train and lives were lost as a result, for example
the accident at Silver Spring in the USA.
At the Waterfall accident, one of the StateRail staff who attended the site attempted to
open one of the doors but he found that the EDR button failed to open the door. This is an
issue that needs further study to investigate if doors can be opened 1/if the carriage is on its
side and 2/ if there is a loss of power and air. Another issue to clarify is if the EDR device
opens all pairs of doors on one side of the car or if the device opens one pair of doors only.
If the “EDR” sign is replaced with a placard that clearly identifies the release mechanism,
there is the possibility that this will make it easier for unauthorised persons to open the
doors and enter the cars when the train is stabled. This could lead to vandals, or persons
posing a security threat, entering the train. To overcome this problem, there should be a
locking mechanism that locks all the doors when the train is stabled. This would mean the
train is secured and render the EDR mechanisms unusable whilst in this mode.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
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4.0 EMERGENCY DOOR OPENING, CURRENT
POLICY
4.1 Current Policy adopted by RailCorp
RailCorp currently have a door security policy. This involves the side passenger doors of the
train being locked as the train is about to move off from the station. Passengers are unable to
override any locking device and unlock and open the doors themselves in an emergency.
Evacuation procedures are dependent upon the train crew unlocking the doors and directing
the evacuation.
The doors are set to “fail” to the locked position in the event of loss of power or air.
However there are exceptions to this. The Xplorer and the Endeavour cars have doors that
are centrally locked, however there is the provision for passengers to open the doors in an
emergency.
The other anomaly is that on some of the older trains, notably “K”, “C”, “S” and “R” sets, the
passageway between cars is not contained and it is possible to fall, jump or climb off the
train through this opening. Passengers have been killed and injured doing this.
4.2 Why this policy was adopted
The door security policy was adopted by StateRail in 1990. The purpose of it was to reduce
injuries to passengers i) through falling from open doorways and ii) after unsupervised
exit.
This policy involved disabling the internal emergency release mechanism that was fitted
to the existing Tangara cars and having it deleted in the future cars. All other cars were
similarly fitted. By 1994 all manual passenger-operated doors were to be eliminated on
suburban CityRail trains.
The policy stated that passengers would not be able to exit unsupervised.
The policy also called for the door motors to fail in the “locked” position in the case of the
loss of electrical or pneumatic power supply.
This policy was endorsed by the SRA Board in 1990. The installation of locking door engines
commenced in 1990 and compliance of the suburban electric fleet was to be achieved in
1994.
There is no information available that indicates that any risk assessment was conducted to
ensure this policy was the correct one to adopt.
4.3 Injuries due to passengers opening doors
The SAD database from RIC/RailCorp was interrogated to search for injuries and fatalities
that resulted from passengers opening doors and subsequently falling from both CityRail
and CountryLink trains. Records are available from 1989. These figures appear in Figure 1.
Information in the “remarks” section of the database did not always adequately explain the
reason for the injury; as a result there may be some inaccuracy in these figures. For example,
in many instances the term “fall from train” is used but it is unclear if the passenger fell from
a doorway or fell between carriages.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
CityRail
CountryLink
Year
Injury
Fatality
Injury
Fatality
Total
1989
37
6
1990
55
9
6
1991
41
8
5
54
1992
52
6
4
62
1993
20
2
1
23
1994
23
2
3
28
1995
30
3
1996
18
1997
13
1
2
2
18
1998
29
3
3
2
37
1999
25
1
2
2000
16
3
2001
6
1
7
2002
10
2
12
2003
8
8
2004 *
3
3
43
1
1
2
71
34
20
28
1
20
Figure 1: Table showing number of injuries and fatalities due to passengers opening doors
and falling from the train.
Note*: the figures for 2004 are incomplete and only cover the first six months of the year
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Figure 2: The total number of injuries and fatalities on both CityRail and CountryLink
expressed as a graph.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
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Injuries and Fatalities on CityRail.
The figures in Figure 1 show a significantly high number of injuries and fatalities until the
mid to late 1990s when the figures start to decrease.
The StateRail door security policy was signed in 1990 and by 1994 all doors were to be
locked on CityRail trains. However it was still possible in many of the cars to force open
some of the doors. Two of the fatalities in 1998, involved young men forcing the doors open
and then jumping from the train. As a result of the continuing injuries through people
forcing doors open, StateRail then ordered a “door motor locking system” to be installed on
all trains. This commenced in approximately 1997, however the modification took a few
years to retrofit to all cars. This door motor locking system was to prevent persons being able
to force the doors open. This explains why injuries continued even once the door security
policy was introduced.
The reasons for the injuries vary and although often categorized under the term “vandalism”
this is not always the case. Certainly there are cases of school age children leaning out of
open doorways or forcing doors open and jumping from the train. However there are several
cases of adults forcing the doors open to either alight from the train at an unscheduled stop,
leaping off prior to the train stopping at a station or jumping off as the train starts to move.
There are cases of elderly persons forcing the doors open as they realised at the last minute
they were about to miss their stop, for example an 89 year old priest pulled the doors open as
the train was leaving a station and other cases of ladies in their seventies or eighties pulling
doors open to get off the train. In these cases the term “vandalism” is not really appropriate;
it gives an unrealistic impression of what is happening and the problem involved. Vandalism
as defined in the dictionary, involves malicious or willful damage to property. Door opening
does not always fall into this definition. The reasons for it happening are often different
from that associated with graffiti or damage to seats. If this problem is to be managed it
must be properly understood.
Injuries and Fatalities on CountryLink
The door security policy differed for CountryLink. The injuries and fatalities involving falls
from CountryLink involved predominately the XPT. When it was introduced into service,
the doors on the XPT could be opened from the inside by the passengers, even when the
train was moving.
Several of the injuries involved people both young and old, opening doors and jumping
onto the platform before the train had stopped. Other examples involved teenagers opening
doors and hanging outside or jumping from the train. In some cases intoxicated passengers
jumped from the train between stops. There was one fatality involving a nine year old boy
who opened the door accidentally believing it was the door to the next car.
As a result of these accidents, CountryLink fitted a flap over the handle to prevent accidental
deployment. However when problems continued, the doors were then centrally locked.
This occurred in the late 1990s.
The Xplorer was introduced into service into 1993. The doors on the Xplorer have always
been centrally locked and controlled by the crew. However the doors can be opened by use
of a key in an emergency. The key is kept behind a glass case which passengers have to break
to access. Following the accident at Baan Baa, two passengers opened the doors themselves
using this escape mechanism,
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
Reduction of injuries by keeping the doors locked
Figure 1 and Figure 2, confirm that for the safety of passengers, the train doors must be
locked when the train is in motion and the doors should not be unlocked until such time
as the train is stopped at a station. The doors should then be relocked as the train is about
to commence moving.
4.4 Review of current evacuation procedures
The train crew are responsible for directing an evacuation and unlocking the doors. The first
preference in the event of an emergency is for the driver to proceed to the closest station
and disembark passengers directly onto the station platform. If the driver cannot get to a
station, the second preference is for the crew to direct passengers in a controlled evacuation,
opening the doors on the side of the train away from any adjacent lines and directing
passengers away from sources of danger.
The procedures call for the crew to receive confirmation from the signaler or from train
control that oncoming trains in the area have been stopped.
Procedures contained in the “Operator Specific Procedures” dated September 2003 instruct
the driver to “do everything possible to stop all trains on adjacent lines”. The driver and
guard then have to agree on a passenger evacuation plan taking into account the risks
present at the time.
From reading these procedures it becomes clear that the driver and the guard have a lot
of decisions to make prior to ordering an evacuation. They need to establish the urgency
of the situation. They need to establish if it is safer to keep passengers on the train rather
than evacuating. The numbers of passengers on board, the dangers present in the external
environment, the protection arrangements required, the safe area to which passengers
should be directed and which doors to open; are all factors to be considered.
The urgency of the situation will dictate to a large extent the protection that the crew can
put in place. Fitting track–circuit shorting clips can be done quickly but it would take
longer to place detonators and these actions would require the crew to leave the train, so
these tasks would only be possible if time was not critical.
For crew to be empowered to make such decisions, adequate training would be essential.
Crew would need to be presented with a variety of scenarios to practise and test these
decision making skills.
Crew would need to practise the conduct of the evacuation in a variety of scenarios
and the making of suitable announcements via the PA. The wording used in emergency
announcements is important, firstly to obtain the attention of the passengers and then
to provide information and direction. The appropriate tone, speed and clarity of voice are
essential to ensure the message is understood. Unless this has been practiced, crew may
have trouble finding the right words to use in the confusion and turmoil that can occur at
such a time. Commands should be short, concise and positive.
The train crew procedures provided by RailCorp have different dates on different documents
and it is unclear what procedures are current. Crew procedures seem to be scattered through
a variety of documents. This can lead to confusion amongst the crew and it makes the
procedures difficult to update as several documents would have to be amended.
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4.5 Emergency Signage
On CityRail trains the emergency information provided to passengers has been a notice
positioned throughout all the carriages that contains the wording:
“In the event of an emergency or a delay, please remain in this carriage and wait for
instructions from staff ”
Words such as please are inappropriate in an emergency instruction as they tend to denote
a request rather than a command.
A memo, dated February 2001, from StateRail Passenger Fleet Maintenance included a
description of the new sign (notice number 3) that was to be fitted to the electric fleet. This
new sign states:
”If the train is delayed, please remain in this carriage and wait for instructions from
staff ”
Note that this new sign provides no information about emergency procedures. On some
trains both these signs are present, however recent inspections of the new Millennium
train has revealed this second sign to be the only one present. This lack of information is of
concern when considering the criticism that has been laid at train operators in the US, the
UK and Canada following accidents regarding insufficient information being provided to
passengers.
These signs all have a white background and are similar in appearance to all the other
“prohibited” notices displayed inside the carriages. There is nothing to denote it is a safety
or emergency sign. It does not comply with the Australian Standard for “Safety signs in the
occupational environment”, which could provide a guide for this type of signage.
There are instructions on the CountryLink trains; however a recent survey of passengers who
were involved in the Baan Baa accident revealed that of the 16 passengers who responded,
four passengers remembered seeing some emergency signage.
There is a lot of information on this topic contained in some of the overseas standards
reviewed as part of this project and in some of the associated research.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
5.0 COMPARISON WITH OTHER TRANSPORT
MODES
There are regulations governing the requirements for emergency evacuation in the other
three public modes of transport operating within NSW, notably aviation, bus and marine.
In these three modes of transport the mechanism for self evacuation (escape) exists.
On aircraft passenger emergency exits are clearly marked, and signage indicating escape
routes and emergency door opening procedures are illustrated. This information is
supplemented by a verbal briefing prior to each take-off, and in regular public transport
operations there is a safety card in front of each passenger.
Before a new type of passenger aircraft is certified to operate in Australian airspace, it must
be demonstrated that a full load of passengers can be evacuated in less than 90 seconds
using only half the available exits.
The requirement for buses to be fitted with emergency exits is covered by the Australian
Design Rule number 58. This stipulates the requirements for emergency windows, doors
and in some cases emergency hatches in the bus. These emergency exits must be capable of
being opened from the inside and from the outside and must be clearly labelled with the
words “EMERGENCY EXIT”.
The Waterways Authority of NSW audits the requirements for commercial craft to have
emergency exits, life saving apparatus and appropriate signage.
There are differences between rail operations and those of the other transport modes. The
ratio of crew to passengers is different; there can be a large number of passengers on board
one train (as many as 1500), with a minimum of two operating crew members, whereas a 747
aircraft for example operates with approximately 18-20 crew and less than 400 passengers.
As there are a limited number of crew on a train, and as they are located away from the
passengers this would have to be taken into account with respect to their emergency training
and procedures. The train crew would be very reliant upon the use of the PA when directing
an emergency unlike other forms of transport where the crew communicate directly to the
passengers. Therefore crew would need to practise making emergency PA announcements as
part of their training. This also highlights the importance of the train having a functioning
PA and the ability of the PA to operate when power has been lost. A faulty PA should be
a no-go item.
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6.0 LESSONS LEARNT FROM PAST ACCIDENTS
Several accidents and accident reports have been reviewed as part of this project and some
of these accidents are summarised here. Some of these accidents are important in that the
resulting accident reports and recommendations had a direct bearing on resulting standards
and rules covering emergency evacuations. Other accidents have produced lessons that are
of value to this project and to the topic of emergency evacuations and emergency response
planning.
6.1 International examples
6.1.1 NORWAY
January 2000: Asta, Norway.
Two passenger trains collided and the diesel tanks on both trains burst in the violent
collision.
Nineteen people were killed in the collision and the subsequent fire and 67 persons survived
the accident. Immediately after the accident there was confusion as to how many passengers
were actually on the train, the operator was unable to provide an accurate figure.
According to rescue workers some passengers survived the crash but perished in the fire
that raged for six hours following the accident.
By the time the fire-fighters arrived, the fire had strengthened to such an extent that it was
not possible to extinguish or prevent it from continuing to spread in the front carriage.
All the efforts of the fire service personnel were focused on saving surviving passengers
in the front carriage of one of the trains where several passengers were trapped. Prior to
the fire-fighters arriving, the passengers had attempted to fight the fire using hand held
extinguishers.
It was not possible to extinguish the fire because of the large amount of diesel fuel present
and the carriage furnishings that were burning. The diesel fire outside the front carriage
was inaccessible to the fire-fighters because of the position of the carriage and the damage
it received in the collision.
6.1.2 AUSTRIA
November 2000: Kaprun, Austria. Kaprun funicular railway.
There was a fire on the Kaprun funicular railway, in a tunnel, carrying skiers up a mountain.
The fire released poisonous fumes which quickly overcame the trapped skiers.
A total of 158 passengers died, 12 passengers survived.
According to the BBC News website, there was confusion regarding the communication
between the train operator and train control. The driver was told to open all doors, however
there seemed to be a delay in this happening.
There are also conflicting reports about whether the train’s doors remained closed, sealing
passengers in the burning train.
The head of technical operations for the company running the railway, said the driver was
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
told to open all doors after an alarm sounded. After another five or ten minutes radio
contact was lost. But a German survivor said the doors had jammed, trapping passengers
inside. “They screamed as they tried to prise open the doors and smash the windows,” he said.
“All I wanted was to get out and I only managed to escape by the skin of my teeth because a window
was kicked open, letting me battle my way out.”
For the passengers who did get out of the train there was no fireproof emergency refuge
or evacuation tunnel through which they could escape. There were no clearly-marked
emergency exits. Some passengers who got out of the front of the train are believed to have
been choked by the fumes as they clambered upwards through the dark, smoke-filled tunnel.
The few who fled downwards from the rear of the train were the only ones to survive.
6.1.3 KOREA
February 2003: Dae-gu Subway, Korea.
A fire was lit deliberately in a train whilst it was positioned at the Dae-gu subway station, by
a person using 4 litres of gasoline. The fire developed beyond control within four minutes,
it then engulfed the entire compartment. It is estimated to have taken approximately 8
minutes to burn down the affected car.
The fire then spread to other compartments. A second train approached, and the subsequent
rush of air caused the fire to spread to the second train. It took 2 minutes and 15 seconds for
the fire to spread from one train to the other.
The Dae-gu subway fire resulted in the death of 192 persons and injured 147 persons.
There was a failure of communication between the train driver and the operations controller.
The operations controller did not fully appreciate the seriousness of the situation. This
delayed the evacuation process allowing the fire to spread to the second train approaching
from the opposite direction.
The extremely flammable and toxic nature of the interior materials of the rolling stock
caused passengers to suffocate. Emergency facilities were inadequate.
According to survivors, the doors of the first train were open, but the doors of the second train
were shut. Passengers complained of locked doors on the train trapping many passengers
who choked to death.
A fire shutter positioned between the subway entrance and the shopping centre at
underground level automatically functioned. Many of the passengers who had escaped the
trains died as the fire shutter blocked their path.
The Dae-Gu emergency system relies on the driver’s action, needing him or her to attempt
to suppress the fire first, before evacuating passengers.
(This contrasts with the Japanese system, where passenger evacuation comes first).
Following this accident the Subway Safety Task Force suggested several corrective measures
be put in place, some of these included:
• “Public education of safety procedures and safety issues (e.g. how to escape from railway
vehicles manually); and
• Universalised manual emergency door system”.
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6.1.4 United Kingdom
September 1997: Southall, UK.
The crash took place at Southall East Junction when a high speed train operated by Great
Western Train Company collided with an empty freight train operated by English Welsh
and Scottish which was crossing to Southall Yard.
Seven people died in the crash and 139 were injured.
An inquiry was chaired by Professor John Uff, and his report included 93 recommendations
aimed at improving rail safety. Several of these recommendations included a review of
emergency evacuation equipment including:
• That a review should be carried out by the Association of Train Operating
Companies (ATOC), on the ways in which internal safety features may be
modified and standardised to provide the best practicable means of emergency exit
under accident conditions, including vehicles lying on their side;
• The provision of emergency lighting and standardised public announcements
should be reviewed;
• A single body should be empowered to specify common standards for safety
features in the interior of passenger vehicles and to identify and approve types of
vehicles and/or operators to which particular standards are to apply;
• Safety briefings or other appropriate means of communicating safety information
to passengers should be adopted, including pointing out safety notices to
passengers; that ATOC should monitor these methods and that recommendations
for different types of journey should be made;
• That train crews should be given improved training and briefing on emergency
actions, including participation in a practical evacuation.
October 1999: Ladbroke Grove Junction, UK.
About two minutes out of Paddington station, a Turbo of Thames Trains collided almost
head on with a high speed train operated by First Great Western. Both train drivers were
killed. The impact was followed by a number of fires caused by the dispersal and ignition
of diesel fuel.
There was no organised evacuation. Passengers had difficulty in knowing how to open the
external doors and how to break windows. Some of the cars had tilted over at a substantial
angle and passengers had difficulty in opening internal doors which had fallen shut due to
gravity.
Many passengers were injured, and 31 passengers died.
An inquiry was conducted by Lord Cullen and the recommendations included improved
safety information to be provided to passengers regarding evacuation, additional research
into emergency exit windows and a greater emphasis on the humanitarian response.
An issue arising at this, and the Southall inquiry, concerned the opening of internal doors.
Passengers experienced difficulties in both these accidents when attempting to open the
internal doors in some of the coaches which had derailed and landed on their sides. They
found that once opened, the doors had fallen shut under the force of gravity. Two of the
experts called to give evidence suggested 1/ the provision of suitable handles to make it less
difficult to move the doors and 2/ the installation of an automatic catch mechanism for
holding such doors in an open position.
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In the report, Lord Cullen recommended that there should be a study regarding the
possibility of installing a telephone by which passengers can communicate with the signaler
in the event of the driver being killed or incapacitated, so as to enable them to obtain advice
and information in an emergency. He made this recommendation with respect to driveronly trains, however this suggestion is also relevant to other passenger carrying trains.
Lord Cullen made recommendations regarding the fuel tanks. He recommended that there
should be a review of Group Standards in respect of improved crash resistance of fuel tanks.
This included utilizing smaller fuel tanks and repositioning the tanks away from exposed
and vulnerable locations. However this issue is outside the scope of this report.
6.1.5 USA
September 1993: Mobile, Alabama, USA.
An Amtrak train derailed whilst crossing a bridge that had been displaced after being hit
by a barge. The train derailed and three locomotive units, the baggage and dormitory car,
and two of the six passenger cars fell into the water. The fuel tanks ruptured and there was
a fire.
Of the 220 passengers and crew on board, 42 passengers and 5 crew were killed, 103
passengers were injured.
This accident raised the issue of emergency response and evacuation procedures and the
need to provide passengers with information regarding emergency equipment.
February 1996: Silver Spring, Maryland, USA.
A collision between an Amtrak passenger train and a Maryland Rail Commuter MARC
passenger train caused the fuel tank of the MARC train to be ruptured and there was a
resulting fire.
On the MARC train all 3 crew members were killed. Of the 20 passengers, 8 were killed in
the derailment and subsequent fire, and 11 passengers were injured.
On the Amtrak train, 15 of the 182 passengers and crew were injured.
The investigation pointed to a lack of appropriate regulations to ensure adequate emergency
egress features on the passenger cars.
The eight fatalities occurred in one car. In this car the passengers were unsuccessful in
opening the left and right rear exterior doors after the accident.
The surviving passengers stated they had known nothing about the operation of the
emergency doors or windows. After unsuccessfully attempting to open the rear doors, the
survivors escaped through a hole in the train.
The investigation found that damage to the doors in the accident had prevented them from
opening.
The investigators from the National Transportation Safety Board (NTSB) concluded
that the absence of comprehensive Federal passenger car safety standards resulted in the
inadequate emergency egress conditions. As a result, the NTSB issued four urgent safety
recommendations, one of which was:
“Install an easily accessible interior emergency quick-release mechanism adjacent to all
exterior doors.”
Another major issue at this accident involved the access to the train by the emergency
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17
responders. The firefighters stated that they could not observe any instructions detailing
how to open the emergency windows or the location of the emergency door release handles
on the car exteriors. In some cases they reported that door opening devices were found to
be missing.
Post accident inspection of the cars found that the exterior emergency door release handles
were missing from one car. The handles on another car were inaccessible as they were buried
in ballast when the car derailed. The handles had originally been designed to be positioned
adjacent to the door, above the bottom of the car body. However, the handles were actually
installed below the floor line of the car and approximately 3 inches inboard, this meant
they were inaccessible when the car derailed. The investigators found there was no existing
requirement for the maintenance or the accessibility of these devices.
As a result of this, it was the recommendation of the NTSB that:
“all exterior emergency door release mechanisms on passenger cars be functional before a
passenger car is placed in revenue service, that the emergency door release mechanism be
placed in a readily accessible position and marked for easy identification in emergencies
and derailments, and that these requirements be incorporated into minimum passenger
car safety standards.”
March 1999: Bourbonnais, Illinois, USA.
An Amtrak train, with 207 passengers and 21 Amtrak railroad employees, struck and
destroyed the loaded trailer of a semitrailer that was traversing the railway crossing.
Both locomotives and 11 of the 14 cars in the Amtrak consist derailed. The derailed Amtrak
cars struck 2 of 10 freight cars that were standing on an adjacent siding. A fire resulted. The
accident resulted in 11 deaths and 122 people being transported to local hospitals.
When the first Bourbonnais Fire Protection District personnel arrived at the accident
scene, they saw that employees of Birmingham Steel had responded to the scene and had
begun the rescue effort. The steel plant employees had brought a number of hand-held fire
extinguishers and ladders from the plant to combat the flames. While some of the steel
plant employees applied the fire extinguishers to the flames, others entered some of the
damaged passenger cars to extricate entrapped passengers. These efforts were continued
for about 45 minutes when the steel plant employees were relieved by the arriving Fire
Protection District personnel.
There was confusion about passenger numbers. Amtrak advised that there were over 400
people on board, however this number was wrong. The fire-fighters spent additional time
searching for an additional number of passengers. It took Amtrak a couple of days to revisit
the passenger manifest and establish the correct numbers of people on board.
6.1.6 CANADA
November 1994: Riviere-Beaudette, Quebec, Canada.
A VIA Rail Canada Inc. train collided with a tractor- trailer at a public crossing. The leading
locomotive derailed and the fuel tank ruptured, fire erupted at the rear of locomotive and
the train continued for approximately 4000 ft before stopping. Railway employees fought
the fire with on board fire extinguishers.
Of the 197 passengers, 2 passengers and 2 staff sustained minor injuries.
The conductor was unable to contact the crew in the locomotive as the train radio had been
damaged in the accident. Conflicting advice was given to the passengers as they detrained
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
as to where they were to proceed. Once outside the train they were apparently directed to
walk to a nearby crossing, but this was a different order from what the conductor was trying
to give. It highlighted the lack of coordination amongst the crew members.
There were eight crew on board the train and they provided assistance to the passengers.
However no one employee was taking control and no pre-determined plan seemed to be
in effect.
The emergency lighting did not activate. There was no exterior emergency lighting to provide
illumination for passengers detraining into darkness. There were no portable flashlights,
only small pen flashlights given to crew which proved inadequate. The lack of lighting
increased anxiety amongst passengers. This issue is repeated in other accident reports.
The PA system did not function on emergency power and the train crew were unable to
communicate basic evacuation instructions to the passengers. The crew had no other backup method such as a megaphone available to them.
These factors explained why passengers received conflicting instructions from different crew
members. In the darkness with the lack of identifying clothing the train crew could not be
readily identified by the passengers.
November 1994: Brighton, Ontario, Canada.
A VIA Rail Canada Inc. train struck a piece of rail intentionally placed on the track. A
fire erupted and the trailing portion of the locomotive and the first two passenger cars
became engulfed in flames. The piece of rail punctured the locomotive fuel tank and severed
electrical power cables.
Of the 385 passengers on board, 46 were injured.
The accident report stated the emergency exit features of the passenger cars did not provide
an acceptable level of safety.
Passengers attempted to move to the rear of the train; however they were unable to open
the door leading to the following car. Panic ensued and many passengers felt they may not
survive. A crew member eventually made her way to the door and managed to open it.
Passengers and staff began breaking windows with their feet. Passengers then started to
escape through broken windows, and this was whilst the train was still moving. Two rail
employees managed to open doors and operate the associated steps that allowed people to
exit the train.
Passengers were injured exiting windows as they received cuts and abrasions from broken
glass. Others were injured jumping from the windows.
The investigation found inadequate information pertaining to the operation of the doors.
Manual operation of the vestibule door was accomplished by pulling down on a “T” handle;
however the investigation found that not all passengers would be able to reach this handle.
It was considered that the force to operate this handle, coupled with lack of instruction on its
operation rendered manual deployment of the door as extremely difficult if not impossible
for some passengers.
There was inadequate signage outside the train indicating how to operate the door opening
device.
A questionnaire was sent to the passengers and the most common observations included:
• The emergency exit windows could not be opened;
• The train crew located in the first two cars where the fire entered became confused
and were unable to give basic instructions;
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• The rail employees could not be identified in the dark;
• The lack of external lighting;
• Passengers felt they were not provided with adequate information during the
emergency.
The investigation found that although train crew were provided with information during
their training regarding the preferred methods of evacuation, they did not get a chance
to practise the task. They received no instruction on communication skills and providing
direction to passengers in an emergency.
Major issues in the accident report covered emergency evacuation and egress. The Canadian
Transportation Safety Board recommended that the Department of Transport take steps to
ensure a suitable standard is introduced.
March 1996: North Bay, Ontario, Canada.
An Ontario Northland Railway train derailed. Eight (8) of the 54 passengers were injured
and 2 of the 6 crew on board were injured.
After the derailment, passengers in the second car believed that steam coming from the first
car was smoke. The emergency windows would not open and passengers exited via the rear
side door which had been opened by the crew from the outside.
There were no written instructions on how to open the side doors.
The end door providing access to the first coach was not in line making it treacherous to
pass from one coach to the other through the end doors. This was attributed to minor
deformation of the car frame.
Major findings included a lack of emergency evacuation information amongst other safety
deficiencies.
September 1997: Biggar, Saskatchewan, Canada.
This accident involved the derailment of a VIA Rail Canada Inc. train following the fracture
of the lead axle of the trailing locomotive.
Thirteen of the nineteen cars and the two locomotives derailed.
Of the 198 passengers and crew on board, 79 were injured, 1 fatally and 13 seriously.
Major problems identified included the lack of adequate emergency training for crew and
lack of emergency information provided to passengers.
Several passengers and crew were injured departing the train into darkness, reportedly
jumping from as high as 4 metres to the ground.
There was no posted written information to advise how to operate the side entrance doors,
which are the primary exits in an emergency evacuation. There were no instructions posted
to advise of the proper operating method of the retractable stairs.
Transport Safety Board (TSB) investigations into previous accidents involving passenger
trains at Brighton and elsewhere, resulted in the identification of hazards regarding passenger
safety. This accident once again raised issues of passengers’ safety and evacuations and safety
briefings. The TSB identified the following short term measures to be implemented. These
measures included the following:
• Safety briefings for passengers
• Passenger’s safety cards
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
• Emergency window exit hammers with signage and instructions for use
• Flashlights
• Emergency signage for all emergency exit routes
• Exterior emergency signage to assist first responders
• Effective emergency PA systems & emergency lighting
• Stowage and restrictions on carry on baggage
• Emergency procedures training for all crew on trains.
The Ministry of Transport stipulated that VIA Rail completed its implementation of these
measures within 30 days.
6.2 NSW Accidents
July 2000: Linden-Woodford.
A CityRail, 4 car InterCity train came to a stand after suffering wheel slip problems. There
were 80 passengers on board.
In the leading car a fire started in the roof and smoke entered the first and second cars
through the air conditioning system.
The crew directed passengers to the two rear cars of the train. The driver and the guard then
left the train to place train protection. Whilst they were away, the police and emergency
services arrived and believed that the passengers were in fact trapped in the rear cars.
The emergency services started to try to gain entry to the train to allow passengers out. Two
security officers (SRA staff ) who were operating on the train, saw this and started to panic
and began smashing windows and trying to unlock doors. This resulted in fear amongst the
passengers. There was a failure of the interface between train crew and emergency services.
Six passengers were taken to hospital with smoke inhalation.
It was identified that there was a lack of training in emergency procedures for train crew
and for security guards.
This accident highlighted that the emergency services were unaware of the significance of
the EDR button and failed to identify it.
October 2000: Kingsgrove.
This accident involved an eight car CityRail, Tangara. The last three carriages derailed and
rolled onto their sides.
Ten passengers suffered minor injuries, the train was lightly loaded and the majority of
passengers were in the non derailed cars.
Overhead electrical wires were brought down and this caused concern regarding isolation
of electrical power. There was no clear communication received that indicated that the
site was “electrically safe”. This caused delay and confusion for the responding emergency
services and delayed the evacuation of the passengers.
July 2002: Hexham.
An empty coal train derailed and as the driver attempted (unsuccessfully) to call the signal
box at Maitland, a second crew member started to place protection on the adjacent lines.
Approximately 8 minutes after this occurred, a two car passenger train collided with one
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of the derailed wagons which were positioned foul of the Down main line. At the time of
the collision the second crew member had not yet placed protection on the Down line. All
carriages remained upright.
The accident report indicated an inadequate communication process in arranging protection
for the derailed train.
The driver and guard of the passenger train and ten of the passengers were injured.
August 2002: Bargo-Yerrinbool.
There was a collision between a ballast train and a four car passenger train. There were no
injuries.
Following the collision communications became confused between the driver of the
passenger train, the signaler and the guard due to equipment being used incorrectly or
being out of range.
The accident investigation report states that the driver had lost situational awareness and he
was unable to 1/ confirm positively to the train controller that a collision had occurred and
2/ advise if all passengers were uninjured. The guard had a radio with a flat battery. Using
his mobile phone, the guard contacted the signaler at Moss Vale as he did not have the
number for the signaler at “Tennessee”. Rail terminology was used that was not understood
by the emergency responders. The train controller did not have an appropriate map that
enabled him to provide the emergency services with directions to the site.
This accident highlighted a lack of an effective emergency response from the crew and
a lack of effective communication procedures. There are many examples in this accident
that highlight the lack of an emergency plan. These same issues arise later at the Waterfall
accident.
Initially police and ambulance officers were attempting to transfer passengers from the
train to the top of the embankment by using ropes to haul each passenger up the side of
a cutting. However a safer route was then found by walking passengers along the base of
the cutting for a short distance to a gentler track. There was a need for better consultation
between the emergency services and rail personnel at the site.
January 2003: Waterfall.
A four-car Tangara train operating from Sydney to Port Kembla overturned at high speed
and collided with a stanchion and a rock cutting approximately 2km south of Waterfall.
When the train hit the staunchion the first and second carriages righted themselves.
Of the 49 persons on board, the driver was deceased (however that was most probably due
to medical reasons rather than as a result of the accident), 6 passengers were killed and 47
passengers and the guard were injured.
As a result the crew were not available to conduct the evacuation and passengers were unable
to quickly escape the wreckage except where the structure had been opened by the crash.
Upon arrival at the site the emergency services did not know how to open the train doors
from the outside, they were unfamiliar with the panels marked EDR that indicated the
position of the “emergency door release” button. In some cases police resorted to using rocks
to attempt to break some windows.
It was discovered that some doors were unable to be opened by use of the external EDR
buttons. According to the accident report this may be due to the weight of the plug type doors
or due to no or insufficient stored air being available. This needs further investigation.
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It was also found that while the multi-layer polycarbonate windows had hampered
passengers’ efforts to escape from the carriages, the strength of the windows had helped
contain passengers during the roll-over.
May 2004: Baan Baa.
This accident involved a collision at a railway crossing, between an automobile and a
CountryLink Xplorer. The train derailed and the front carriage ended up on its side, with the
fuel tank ruptured. There were some injuries and two passengers required hospitalization.
As the front car tipped over, the coupling between the carriages broke, leaving the second
car upright. This exposed a doorway at the rear of the first carriage through which the
passengers were able to exit. However as the train was on its side, it was very difficult to
climb through the carriage, over seats, baggage and the spilt hot water from the buffet.
The two photographs that follow show the inside of the first carriage and illustrate the
difficulties that would be experienced by passengers when the car is in this state.
Figure 3: Photograph of the first carriage of the Xplorer involved in the accident at Baan
Baa. The photograph is taken looking forward towards the door that provides
entry into the driver’s cab.
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Figure 4: Photograph that illustrates the difficulty that would be experienced by passengers
when moving through a carriage that is on its side. This photo also shows the
difficulty that would be experienced when opening a door such as that leading
to the driver’s cab when the car is in this position.
The Office of Transport Safety Investigation sent out a survey to the passengers involved in
this accident to seek information from them regarding emergency evacuation.
Generally the survey indicated a lack of emergency information being provided to the
passengers. Of the 17 passengers who responded to the survey, three remembered seeing
some written instructions regarding emergency procedures.
Passengers reported having difficulties getting out of the train, due to being injured, being
in pain, having other passengers on top of them, having to crawl over seats, over glass
windows, over hot water spilt from the buffet, suffering from shock, smelling and seeing
fuel lying everywhere. Some passengers recalled that people were shouting and screaming
to “get out urgently”, feeling panic as they thought the train would explode or a fire would
start due to the spilt fuel.
These types of passenger surveys can be most useful in obtaining details of the passengers’
experience in the aftermath of the emergency and should be considered in the future
following similar occurrences.
Two passengers in the first car described how they helped the driver from his cab and assisted
him out of the rear of the carriage. As can be seen by the photographs on the previous page,
the design of internal doors is important when the cars end up in an unusual attitude.
Gravity can make the doors very hard to open and to keep open. That is why there should
be some device to keep the door open. These findings are reflected in some of the overseas
standards. For example, in the UK, the ATOC Vehicle Standard requires that internal
doors should be hinged from opposite sides or should slide in opposing directions.
This accident also indicated a lack of any suitable response planning by CountryLink to
follow up on the passengers, many of whom are angry at having heard nothing from the
organisation.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
6.3 Findings from Rail Emergency Exercises
Train Disaster Field Exercise “Blue Rattler”
This exercise was conducted in May 1997, in the Sydney underground railway tunnel
system between Wynyard and Town Hall stations. It was a full field exercise with the State
Rail Authority participating along with all the relevant emergency services. The scenario
involved the detonation of an incendiary device aboard a passenger train.
The exercise involved 40 “passengers” on the train at the time of the emergency. In this
exercise it took two hours to evacuate the passengers from the train to safety outside the
station. This was with only 40 passengers involved whereas there can be trains traveling at
peak hours within the city carrying around 1500 passengers.
It was the unanimous view of all the combat agencies who attended the exercise that had
this situation been a real event it is most probable that all the passengers would have died
from fire or smoke either on the train or in the tunnel.
The major issues identified at this exercise included:
• The deficiency of communications, both via the telephone system within the tunnel
and communications from the train;
• The lack of a smoke extraction system and a ventilation system within the tunnel;
• The lack of any smoke, fire detection or fire suppression system in the tunnel;
• The fact that passengers were unable to open doors themselves and self evacuate;
• The responding emergency services did not know how to open the train doors from
the outside;
• The ladders used for passengers’ egress from the train down to the track are difficult
to use. Elderly passengers or those with mobility problems would find the ladders
very awkward;
• The exercise highlighted the difficulties in removing injured passengers from a train
in this situation;
• Once they had arrived at the station it took a long time for the emergency services
to reach the train.
In the opinion of the responding emergency services they all expressed concern regarding
the difficulties encountered regarding train access; the total reliance by the passengers on
the train crew to open the doors and the need for additional emergency response training
for rail personnel and train crew.
Operation “Join Forces”
This exercise was held on the 10th July 2004, in the Sydney underground railway tunnel
system at St. James station. The exercise involved RailCorp personnel and a few observers
from the Independent Transport Safety and Reliability Regulator. The exercise involved
four scenarios, including a controlled evacuation from a train stopped within the tunnel due
to a technical problem, and a fire on a train and a subsequent evacuation.
The train used in the exercise was positioned about 100 metres south of St. James station.
As a result the “passengers” were evacuated to the track via the use of stairs placed at the
front of the train. Several issues were noted during this exercise:
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• Inappropriate announcements made over the PA by the train crew. The guard made
several announcements in which he sounded very stressed and scared. In a real
event this would have had the effect of alarming passengers;
• There was a conflict between the announcements made by the guard and that made
by the driver. Whilst the driver was asking people to remain calm, the guard was
directing people to make a “speedy evacuation”;
• Some of the transit officers were involved in the exercise, and this showed the
importance of having these officers trained so they can assist with an emergency
situation. In one of the exercises, the author of this paper observed that the officers
remained calm and provided a calming effect to the “passengers”, the fact they are
in uniform gives them a degree of authority;
• The ladder positioned at the front of the train is awkward to use. Elderly passengers
or those with mobility problems would have difficulty;
• There is the potential for passengers to be injured as they descend the ladder onto
the ballast which is very hard to walk upon. If passengers descended the ladder in a
hurry or if they tried to jump they could fall on the ballast below;
• Had this been a real event rather than just an exercise, it is most likely that some
passengers would have jumped off the train between cars to avoid waiting in the
queue to get off at the front of the train.
Although problems were identified, RailCorp are to be commended for holding this exercise.
It is through the conduct of exercises that problems can be identified and emergency plans
and procedures can be improved.
6.4 Review findings from past rail accidents.
In the preceding reports there are examples of fires on trains, accidents within tunnels and
accidents occurring as a result of collisions between road vehicles and between other trains.
There are accidents in remote areas, in metropolitan areas and off bridges into water. Train
operations within NSW operate in all these types of environments.
Running through many of these reports are some common themes. The need for improved
signage and instructions provided to passengers to ensure they are better prepared to respond
appropriately in an emergency is repeated in several accident reports as is the need to ensure
the escape devices are maintained and easy to use.
Some of these accidents are significant in that they brought about tighter rules and regulations.
The USA, Canada and the UK imposed stricter regulations as a result of recommendations
from investigations involving some of these recent accidents; to be specific this included the
major accidents at Silver Spring and at Mobile; at Brighton and Biggar; and at Ladbroke
Grove respectively.
Even though the ability for passengers to self evacuate existed in these specific accidents,
the reports found that the provision of inadequate emergency information doubled with
inadequate lighting contributed to injuries and in some cases fatalities.
6.4.1 Emergency Procedures
Another recurring issue throughout these accident reports is the inadequacy of the crew
response and the inadequacy of the emergency response by the operator. This is evidenced
by recent accidents within NSW, where crew did not effectively manage the evacuation of
passengers and where the operator’s emergency plan did not adequately provide protection
for the accident site. The lack of effective procedures to enable quick and informed
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
notification to the emergency services and effective interaction with the emergency services
whilst on site are other reoccurring themes. These same issues arose in the exercise “Blue
Rattler”.
The issue of crew training arises again in the two exercises described in section 6.3. This issue
needs further investigation. If train crew are to be responsible for conducting an effective
controlled evacuation they need to be equipped with the necessary tools to accomplish this.
This means adequate training, practise in the use of the PA and serviceable and reliable
communications equipment.
6.4.2 Emergency Access
In some accidents both overseas and within NSW, emergency services personnel have been
delayed in gaining access to the train by being unable to locate or operate external door
opening devices. This issue arose at the Waterfall accident and the earlier exercise “Blue
Rattler”. Emergency responders did not understand the term “EDR”. The panel covering
the EDR device is not identified as being a piece of emergency equipment.
Some of the recommendations from accident reports included in this section are that clear
signage and instructions are to be placed outside the train for the information of responding
personnel.
To train all emergency services personnel in the term EDR would be very difficult due to
the numbers of staff involved throughout NSW and the high turn-over of staff, especially
in the voluntary organisations.
6.4.3 Diesel and Electric trains
Three of the accidents described previously in section 6.1 resulted in major fires as a
consequence of collisions involving diesel powered trains, notably Ladbroke Grove in the
UK, Silver Spring in the US and Brighton in Canada.
Both the trains involved in the accident at Ladbroke Grove, the Turbo and the High Speed
Train, were diesel powered. Upon impact there was an almost immediate development of
fireballs and subsequent fires on and around the trains. It was agreed that the source of fuel
for the fireball was finely dispersed diesel fuel.
Much of it came from the contents of the fuel tank of the front car of the Turbo which
contained 688 litres at the time of the crash. The presence of diesel fuel inside one of the
coaches (coach H) played a significant role in the development of the fire from its early
stages. Mr Christie of Geoffrey Hunt & Partners, who was called to the subsequent inquiry
as a specialist in the investigation of fires and explosions, explained that in the early stages
the predominant factor was the combustion of diesel fuel. He stated it was inevitable that,
when an accelerant was burning on a material, even one which was normally fire-retarded,
there would be an eventual stage where the material could no longer resist the fire. He
believed that diesel fuel could have entered the coach by way of broken windows, openings
at each end of the coach and/or areas where the body of the coach had been damaged.
It was agreed between the experts that this fire spread through the coach over the course of
seven or eight minutes until it fully engulfed it. Of those passengers who remained in coach
H after the impact of the crash, all but one managed to escape from the coach before fire
engulfed it. The majority of the combustible materials within the coach were then consumed
over a period of about 30 minutes.
There were many potential sources of ignition. The most likely were the overhead line
equipment, the onboard electrical systems and sparking, all three of which were almost
certainly present.
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Another example of a catastrophic fire involving diesel operated trains was at Silver Spring,
involving the collision between an Amtrak train and a MARC train. The subsequent
investigation found that the fuel tank of the Amtrak lead locomotive unit had catastrophically
ruptured open during impact. The fuel had then ignited and sprayed over and engulfed the
MARC cab control car.
At Brighton the piece of rail punctured the fuel tank and the severed electrical power cables
provide the source of ignition.
Even though diesel is a relatively stable product, these accidents prove that given the right
conditions such as fuel escaping under pressure and the presence of an ignition source, a
fire can result.
While electric trains would not have the same potential for ignition as that of diesel trains,
both electric and diesel trains operate within NSW and they use the same tracks and
infrastructure, so the potential for collision between the two types is possible. The majority
of trains operating within NSW are now built with fire retardant material; however there are
some examples of older passenger trains still in use that would not be of the same standard.
Some of the older diesel trains, notably the 620 and 720 cars, have interiors lined with wood
panelling that would pose a greater risk in the event of fire. So it needs to be recognised that
there are some differences between trains operating currently within NSW, and this should
be taken into account with respect to emergency procedures and crew training.
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7.0 FINDINGS FROM THE WATERFALL
COMMISSION OF INQUIRY
The Waterfall accident was an example of the train crew being disabled and unable to direct
the evacuation. Emergency services had problems gaining access to the train and passengers
had difficulties getting out.
The issue of RailCorp’s door security policy was raised several times during the Waterfall
Inquiry.
7.1 Evidence from Mr Heumiller
On day 84 of the inquiry (15th March 2004) evidence was given by Mr Donald Les
Heumiller. Mr Heumiller is an engineer who worked on the construction of the Tangara
train. He was questioned extensively regarding the door security policy of StateRail and the
inability of passengers to be able to open doors in an emergency.
He was not in agreement with the StateRail policy. He believed that the trains should have
doors capable of being opened by passengers following an emergency. When questioned as
to how this could be achieved whilst at the same time trying to prevent people accidentally
(or deliberately) opening the door when they should not, he offered a few suggestions.
He suggested that the mechanism to operate the door in an emergency could be 1/ placed
under a break-glass cover and 2/ could be related to the speed of the train. He explained
that there are speed sensors on board the train which allow for the activation of various
operations electrically. It is possible that the doors could be locked until such time as the
train was below a predetermined speed, for example 3 km/hour. This would mean that if a
passenger did inadvertently open the door the effect would be benign.
He stated that the train could be so designed that unless it was stationary or close to
stationary the emergency door release mechanism would not operate. Or if the train was
stationary and delayed, then the passengers would have to break the glass to get at the
emergency door opening device.
There could also be a time delay fitted to the emergency door release, so that if it were not
an emergency and someone were improperly using the emergency door release, when they
break the glass and pull the handle for example, then an alarm bell would ring in the guard’s
compartment. If there was no obvious reason why the doors should be opened, then the
guard could simply override that by pressing some other button or taking some other course
of action.
Mr Heumiller indicated that the above features were not technically difficult tasks.
During his evidence, the use of CCTV to monitor any vandal activity at the emergency
doors was mentioned as being possible.
The inclusion of a ramp or ladder for passengers to get from door down to the track was also
mentioned, as escaping from a train can be awkward if the train is not stopped at a station
platform. Jumping from the door down to the track could result in injury.
7.2 Evidence from Mr Frankovic
Several passengers gave evidence and reported on difficulties experienced in trying to get
out of the train. For example, on day 11 (8th April 2003), there was evidence from Mr
Frankovic.
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He was very scared and believed that there may have been a fire following the accident.
He assisted another passenger in trying to break a window to escape. He described the
situation as being in a box, “a potential death trap”. He could see no other way to get out of
the train.
7.3 Evidence from Mr Johnson
On day 24 of the commission (8th May 2003), David Edwin Johnson, a train driver employed
by StateRail, gave evidence. Upon hearing of the accident the morning it happened, Mr
Johnson had proceeded directly to the site to see if he could offer assistance. He lived nearby
and was able to reach the site within an hour, arriving at the same time as some of the police
and the Rural Fire Service.
He saw that the police were having trouble entering the train cars. He went to the third
car, which was on its side, and operated the emergency push button (the EDR) however he
stated that “due to the fact that the car was on its side there was insufficient air pressure to push
the doors up before they open.…..they didn’t get far enough up to start opening, so I couldn’t get
into that car”.
Mr Johnson stated that the emergency reservoirs were probably intact, this led him to
believe that there is insufficient pressure to enable the doors to be opened when the car on
its side.
He reported that the attending police wanted to get in the car as a matter of some urgency
and they used a large rock to break the glass in the door in an attempt to gain access.
Mr Johnson then met up with the train guard from the stopped northbound train, (the
train on the Up had been stopped just north of Helensburgh) who had walked up to the
accident site. The guard had obtained the door emergency release bar from underneath the
guard’s seat of the affected Tangara.
Mr Johnson and the guard then went to the second car to attempt to open the doors. They
were unable to open the doors on the southern end of the carriage as the carriage was
buckled. They were able to open the doors at the northern end of the car.
Mr Johnson then went back to the inside of the third car to use the door release bar to try
and open those doors in that car, however the bar had become bent and the thread could not
be inserted into the other doors, it had become useless after attempting to open the doors
on the second carriage.
On returning to the third car, Mr Johnson found that with the glass removed from that door
there was enough air pressure to push the doors up with a bit of assistance. The emergency
services were then able to open the doors and put ladders into the third car. This enabled
them to get people in and out using the ladders.
Mr Johnson was then ordered off site by the crew area manager, his supervisor.
Whilst giving evidence at the commission, Mr Johnson was asked if he had any suggestions
that could assist getting the train doors open when the cars are on their side. He offered the
following solutions:
1. the doors could be made of a lighter material. The two panes of glass currently used
in the door are very heavy;
2. the use of a removable runner so the windows could fall out easily; and
3. that the emergency air reservoir pressure could be increased to an extent where it
would be able to lift the doors when the car is positioned on its side.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
Mr Johnson stated that nobody at the scene knew how to open the train doors, nobody
knew about the EDR button. He stated that he “walked up probably an hour after the incident
and just pressed the button and the door opened straight away on the second car and no-one had
actually thought to do that because no-one knew about it”.
He recommended that a sign or sticker should be placed next to the emergency buttons so
they could be recognised by the emergency services. He did not believe it was possible to
train all the emergency services personnel on train entry equipment.
7.4 Evidence from Mr Lauby
Mr Lauby, formerly from the National Transportation Safety Board (NTSB) in the US,
assisted the Commission. He gave evidence on day 62 (29th July 2003) to the Commission
regarding train operations within the US. Trains are required to have emergency doors and
windows that can be opened by passengers in each passenger car. The emergency exits are
marked on the outside of each car by prominent luminous and reflective signs. Mr Lauby
stated that although there are times when it is best to keep passengers inside a train in an
emergency, there are other occasions when the passengers need to be able to escape.
Mr Lauby used two examples of rail accidents where escape was necessary, the accident
at Mobile, Alabama; and the collision at Silver Spring in Maryland. He stated that these
accidents provided a great learning experience in the US and brought about new regulations
relating to the working of emergency exits and the location of door release mechanisms.
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8.0 OTHER REPORTS AND ASSOCIATED RESEARCH
As part of this project some other associated reports and research were found that were
relevant. Some of these are briefly described in the following section.
8.1 Comparison with other operators
A report commissioned earlier this year included the results of an international survey
regarding emergency access and egress. The resulting report is dated 6th April 2004.
The authors of the report surveyed eight non-identified railway operators; two from
Australia, two from the US, two from Asia, one from the UK and one from Northern
Europe.
Results of this survey indicate that the two Asian operators evacuated passengers by having
them move along the train which has open gangways between cars, and then proceed into
the crew compartment which is accessible by passengers in an emergency. The passengers
then detrain out of the end detrainment doors. No emergency escape device is fitted to allow
passengers to open side doors. However both these operators run systems in a metropolitan
environment and the majority of the route is in a tunnel or on an elevated structure.
Of the other operators surveyed, all advised that on their trains the side doors are always
operable by passengers in an emergency. Some also provide emergency escape through
emergency exit windows.
One Australian operator replied that the side doors can be forced open in an emergency but
new trains are being provided with emergency release devices on the doors (windows do not
form part of their emergency egress strategy).
8.2 Research conducted by Professor Galea
Professor Galea, Director of the Fire Safety Engineering Group at the University of
Greenwich in the UK, has conducted research on passenger evacuation from different
transportation modes, including marine, aviation and rail. He carried out a project on
“Evacuating an overturned smoke filled rail carriage”.
He argues that there is a requirement to ensure that “rail vehicle design and crew procedures
are adequate to allow the safe egress of passengers under a variety of conditions”. He has
carried out tests on evacuations from overturned and partially overturned carriages. Due to
his expertise in the area of evacuation he was called as an expert witness at the inquiry into
the accident at Ladbroke Grove.
He is of the opinion that there should be more consideration given to “improving safety
related signage onboard trains and the oral communication of safety information to
passengers”. On intercity services he suggests additional oral and written information
should be provided to passengers in a somewhat similar fashion as is used on passenger
aircraft.
He suggests that accident investigators should consider carriage design and passenger
survivability factors whenever there is an evacuation from a train, no matter how minor
the incident was, as valuable lessons can be learnt as they have from aviation incidents and
accidents.
He hopes that the rail industry and rail regulators will “explore these issues as they have a
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
demonstrated impact on passenger survivability and hold the potential to make an already
safe form of transport safer by design”.
8.3 Research into Emergency Door Release conducted by
Interfleet Technology Ltd.
Interfleet Technology Ltd., based in Derby in the UK, was commissioned by Railway
Safety (UK) to undertake research into emergency door release mechanisms with emphasis
on signage and illumination. This project was carried out in response to recommendations
made by the Ladbroke Grove inquiry.
Generally this project concluded that information provided to passengers should be clear
and concise. Ideally wording on signage should be reinforced with pictograms where
possible. However signage should not rely on the use of pictograms solely. Emergency door
opening instructions should be located adjacent to the door to which it refers. The signage
must not block any panels or covers that protect the door opening or unlocking device. To
avoid confusion, other unrelated signs should not be in the same vicinity.
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9.0 REVIEW OF LEGISLATION AND STANDARDS IN
SOME DEVELOPED COUNTRIES
A review of any existing standards and legislation covering emergency access and egress on
trains was conducted to see what was in place in some other countries. There are currently
no standards in place within NSW that cover this issue. This study focussed on what was in
place in the UK, the USA and in Canada.
9.1 United Kingdom
There are several standards in place in the UK covering the issue of emergency evacuation.
Some of these are covered below. Following the Southall and Ladbroke Grove accidents,
these standards were amended and criteria covering passenger escape equipment became
more prescriptive.
9.1.1 British Standard BS 6853:1999
British Standard, BS 6853:1999, “Code of practice for fire precautions in the design and
construction of passenger carrying trains”, came into effect in January 1999 and it was
amended December 2002.
Section 10 of this standard covers passenger and crew escape requirements.
It states that “all trains should have doors which can be used for emergency exit.” The standard
covers distances of seats from the nearest emergency exit, “no passenger seat should be more
than 15 m from an emergency exit door on the train,…”
In the case of trains that are designed for running on routes where emergency evacuation
from the sides of the train is not possible, this section states that “the emergency doors should
be at the ends of the train, and it should be possible to gain access to both of these doors from any
part of the train.” This is the case with trains operating in the London Underground, where
the risks of permitting passenger evacuation from the sides of the train are considered too
great. The London Underground procedures call for the evacuation of passengers to be
managed by the crew who are trained in this role and who have a good knowledge of the
operating environment.
Section 10.2 covers the “Properties of emergency exit doors”. This section states that
“Emergency doors, which are normally, or which may be, locked should be capable of being opened
in an emergency by passengers without the use of keys or tools.”
Section 10.3 covers “Powered external doors”. This section states that “Power operated external
doors should be capable of being opened in an emergency by passengers, without the use of keys or
tools, from inside the vehicle even if the power or powered operating mechanism has failed.”
Sections 10.4 and 10.5 cover the requirements for internal doors. Power operated internal
doors should be capable of being opened without the use of any keys or tools, even if the
power has failed. Swing doors in corridors should swing in both directions, but if only a
single direction is possible then this should be towards the nearest external door.
Section 10.6 covers the requirement for emergency lighting to be available for 90 minutes
after losing main power.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
9.1.2 Power Operated External Doors on Passenger Carrying Rail
Vehicles GM/RT 2473
This Railway Group Standard is dated February 2003. Railway Group Standards are
mandatory. This is a document that is most relevant to this project. This standard came into
effect on January 1st of this year. It mandates that only power operated external doors are to
be fitted for passenger use on trains. It stipulates that to ensure safety of the occupants doors
are to be prevented from opening whilst the train is in motion, or, when the train is stopped
away from a platform and/or it is not safe for the doors to be opened.
However, this standard stipulates that each external door is to be fitted with an external
emergency access device to enable the doors to be opened from the outside when the train
is at a standstill and that this mechanism must be operable irrespective of the vehicle power
supply at the time. The operating instructions for this mechanism are to be clearly labeled.
It is also stated that each door is to be provided with an internal emergency egress device
so doors can be opened from the inside by passengers irrespective of the power supply.
However, the door will only be able to open when the train speed is less than 5km/hour.
Again the device is to be clearly labeled and there should be instructions for its use.
9.1.3 Emergency and Safety Equipment and Signs on Rail Vehicles.
GM/RT 2177
This Railway Group Standard, dated January 1995, covers the requirement for safety and
emergency signs to take priority over other signs. It provides guidance on the information
that should be covered in emergency signs in that the text and layout of the sign must reflect
the importance of the information. For example:
1st piece of information would name the equipment;
2nd piece of information would describe its operation;
3rd piece of information would advise restrictions in its use;
and lastly information to deter inappropriate use, for example the penalty imposed for
improper use.
9.1.4 ATOC Vehicles Standard: AV/ST9002: Vehicle Interiors Design
for Evacuation and Fire Safety.
ATOC standards are not mandatory but are advisory. Issue One of this document was
published in December 2002. This standard was produced on behalf of the Association
of Train Operating Companies (ATOC) by Railway Safety. It is intended for use by the
railway industry and it is expected that all companies contributing to the supply of new
railway vehicles to operate in the UK will comply with its requirements.
The purpose of this document is to ensure the interior design of rail vehicles provides
passengers and crew with adequate opportunity to evacuate and escape from a train in the
event of an emergency.
The standard, in a similar fashion to the requirements for aviation, stipulates a minimum
time that passengers should be evacuated. Section 6.1 a) states that:
For side evacuation, ……with maximum passenger loading conditions….all passengers shall be
evacuated to platform level in a period not exceeding 90 seconds.”
Section 6.1.1 stipulates that no passenger seat may be located greater than 12 metres from
a bodyside door or a bodyside emergency escape exit on both sides of the vehicle.
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This same section states that:
“Power operated bodyside doors and manually operated slam doors fitted with a secondary
locking system shall have emergency door release facilities adjacent to each door.”
This standard stipulates that if there is some type of removable cover over the device that
operates the escape exit, the removal of it or operation of the emergency device must not
entail the use of tools or keys. However the cover should adequately deter unauthorised use
under normal conditions.
This standard also covers the operation of internal doors. Section 6.1 of this standard covers
the requirement that passengers should be able to open internal doors regardless of the state
of power. To overcome the problems associated with operating internal doors when the car
has derailed and is wholly or partially overturned, this standard states that:
“…internal doors shall slide open in opposing directions or be hinged from opposite sides
at each end of the passenger saloon….”
9.2 CANADA
Following the accidents at Brighton and at Biggar, the Canadian rules and standards were
amended as a result of the recommendations made by the Canadian Transportation Safety
Board in response to these accidents. As in the US, Canada requires that each passenger car
has no less than four emergency windows per passenger carriage.
In recent discussions with the Railway Association of Canada (RAC), they do not record
many instances of vandals tampering with emergency door release mechanisms. If a door
opening device is operated inappropriately, then an indicator light would illuminate in the
driver’s cab and the train would stop.
The RAC also indicated that the information provided in the form of a safety brochure to
passengers, advises passengers to keep away from other train tracks in the event they do
need to escape the train.
9.2.1 Railway Passenger Car Inspection and Safety Rules
The Railway Association of Canada (RAC) produced these passenger car safety rules.
The most recent issue is dated 8 November 2001. These rules prescribe minimum safety
standards for passenger cars.
These rules stipulate that any powered doors and steps must have provision for manual
operation in the event of a system failure. The preferred means of evacuation is for it to be
controlled by the crew. However, these rules ensure that passengers will be able to open
doors themselves as a last resort (reference section 19.3).
These rules also cover emergency exit windows. Section 20.2 states that “each passenger car
shall have at least two accessible emergency exit windows free of obstructions installed on each side
of the car, located near each end of the car, for a total of four emergency exit windows.”
In addition these rules stipulate that there should be clear, visible instructions for passengers,
that emergency equipment should be visible and accessible in each car, and that the interior
finishes of the car should be free from any sharp objects or projections.
9.2.2. Railway Passenger Handling Safety Rules
These rules produced by the RAC cover the requirement for railway operators to have
documented passenger handling safety plans that cover different types of emergencies from
derailments to terrorist threats and that crew should be trained in these procedures.
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9.3 USA
Since 1970 it has been a requirement in the USA that all passenger carriages should have
a minimum of four emergency windows. The accidents at Mobile and at Silver Spring
resulted in changes to the US legislation and standards as a result of the findings and
recommendations made by the National Transportation Safety Board (NTSB). These
accidents highlighted that it was necessary to maintain emergency exits, both doors and
windows, and to provide adequate information and signage to passengers regarding their
use.
During the NTSB’s investigation into the Silver Spring accident, concern was expressed
that unsafe conditions that had been identified on the MARC train may exist on other
commuter lines. In 1996 the NTSB recommended that the Federal Railroad Administration
(FRA) should inspect all commuter rail equipment to ensure that there were easily
accessible emergency release mechanisms located adjacent to exterior doors and that there
should be removable windows and prominently displayed emergency signage. The NTSB
were concerned that the emergency release mechanisms for the exterior side doors on the
MARC train were located in a secured cabinet some distance from the doors that they
controlled. The cabinet required a screwdriver and a coin to open it. This was done to prevent
inappropriate opening of the door whilst the train was in motion.
The new ruling implemented as a result of this finding was that emergency release
mechanisms for exterior doors should be well marked and relocated so they are positioned
adjacent to the door that they control. The new ruling permitted rail operators to protect the
emergency release mechanism from casual use by placing a cover or screen over the device.
However, this screen must be able to be removed without the use of any tool or special
implement.
The FRA issued Emergency Order No. 20 that required emergency exits to be clearly
marked and in operable condition on all passenger lines. This order required the position
of emergency exit locations to be clearly marked both inside the car for the benefit of
passengers and external to the car to assist emergency responders.
In recent discussions with the Federal Railroad Administration (FRA) in Washington
D.C., they advise they are currently in the process of considering revisions to enhance
these standards. They also advised they had few instances of vandals operating doors and
windows inappropriately. They did recall a few instances some years ago, where there was
a power failure and due to the lack of air conditioning and extremely hot conditions in the
carriage, passengers popped the emergency windows to get air.
Some of the relevant standards include the following:
9.3.1 Federal Railroad Administration (FRA) Code of Federal
Regulations – 49 CFR Chapter 11 (10-1-03 Edition)
These regulations, 49 CFR, are federal law and are therefore mandatory. They include the
need for emergency windows and doors that can be opened from both inside and outside
the car by use of a manual override feature.
Each passenger car is to have a minimum of four emergency window exits, designed to
permit rapid and easy removal from the inside of the car in an emergency situation, that do
not require the use of any tool or special implement.
Each passenger car is to be equipped with a manual override feature for each powered
exterior side door. Each of these manual override mechanisms must be capable of releasing
the door to permit it to be opened, without power, from both the inside and outside of the
car. Each of these devices must be located adjacent to the door which it controls.
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The rail operator may protect these emergency door opening devices by placing a cover or
screen over the devices. These covers must be capable of being removed without the use of
any tool or implement.
All door and window emergency exits are to be marked and instructions provided for their
use.
All door exits intended for emergency access by emergency services personnel are to be
marked with retro-reflective1 material with clear and understandable instructions.
Emergency lighting is to be provided in each passenger car supported by a back-up power
supply that is capable of operating in all equipment orientations and for a time period of
not less than 90 minutes.
Passenger compartment end doors (i.e. doors that provide access to the next car) are to
be equipped with a kick out panel, pop-out window or other similar means of egress in
the event the door will not open, or alternatively, they are to be designed so as to pose a
negligible probability of becoming inoperable in the event of car body distortion following
impact in an emergency.
Also covered is the need for operators to have in place an emergency plan to ensure an
appropriate response. It covers the subject of staff training. After initial training, train crew
are to receive periodic training at least once every two years thereafter. The same applies to
control centre personnel. This regulation also specifies the number of full-scale emergency
exercises that each rail operator should conduct.
Under the heading of “special circumstances” the operation of trains within tunnels is
identified as needing special consideration. The train operator’s emergency plan must reflect
procedures designed to protect passenger safety in an emergency situation occurring in
tunnels of 1,000 feet or more in length. For example the plan must include the provision
of emergency lighting, access to emergency evacuation exits, ladders for detraining and
effective radio or other communications.
The issue of escape hatches in the roof of the train is covered in the section titled “Emergency
roof entrance locations”, which states that each passenger car is to have a minimum of one
emergency roof hatch. This issue has been debated, with the major operators expressing
concern about the inherent dangers of such a hatch. As an alternative, this regulation
continues on to state that instead of a hatch, there must be at least one clearly marked
structural weak point in the roof to provide quick access for properly equipped emergency
response personnel.
This item may need further discussion in NSW. Due to the presence of overhead electrical
wiring, escape hatches would not be viable. As an alternative, it may be possible to distinguish
areas in the roof of the carriages that identify the best place for the emergency rescue
personnel to cut to gain quick access to the car. This could be most useful when the cars are
on their side. This would be similar to what is currently used on many types of aircraft. The
best area for the rescue personnel to cut through is identified and marked. This is an area
that would avoid items such as hydraulic lines, bundles of wiring or other such obstacles.
This would entail no structural work, rather the identification and marking of areas. There
would be no indication inside the carriage.
Some parts of these regulations do not apply to tourist, scenic, historic or excursion
operations.
1
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retroreflective material: material that reflects the light emitted by a light source back to that source.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
These regulations are currently being reviewed. One of the issues being reviewed is that of
emergency communications from the train to the train control centre. The FRA considers
it vital that effective communications can be achieved to assist with the protection of the
site and the halting of any oncoming trains. They believe each passenger train should be
equipped with both a primary and a secondary means to communicate. They stress that
these two means of communication must be required to operate correctly before a passenger
train is dispatched.
9.3.2 Standard for Emergency Signage for Egress/Access of
Passenger Rail Equipment.
This standard, APTA SS-PS-002-98 Rev 1, published by the American Public Transit
Association (APTA)2, provides detail regarding emergency signage, including the minimum
letter height that should be used on signs that indicate the location of emergency windows
and door exits and the requirement for all interior emergency signs to be clearly decipherable
from a minimum of five feet under emergency light illumination.
9.3.3 Standard for Emergency Evacuation Units for Passenger Rail
Cars.
Instead of prescribing how many exits each car should have, irrespective of its configuration
and carrying capacity, this standard, APTA SS-PS-003-98 Rev 1, provides a formula to
provide an acceptable level of escape windows and doors based on the car design. This will
ensure a sufficient number of exits to allow passengers to exit within a prescribed time. The
term used in this standard is Emergency Evacuation Units (EEU). A car manufacturer must
determine the correct combination of emergency windows and exits required to facilitate an
acceptable emergency egress system and this is measured in Emergency Evacuation Units
(EEU).
2
These standards were developed for the 19 commuter railroads and Amtrak that come under the jurisdiction
of the Federal Railroad Administration (FRA). The standards are mandatory, in that all operators agreed
up front to abide by them. However, APTA has no enforcement power.
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10.0 REPORT ON FIRE RISK ASSESSMENT
A report was prepared for the State Rail Authority (SRA) in 1999 by Det Norske Veritas
Consultancy Services. This was in response to a request by the NSW Department of
Transport. Following the VIA Rail Canada accident at Brighton, Ontario, where forty-six
passengers were injured after a fire erupted, the NSW Department of Transport asked SRA
to assess the implications of the accident with respect to their operations within NSW.
This study carried out by Det Norske Veritas involved, amongst other things, a review of the
existing emergency evacuation arrangements in place at SRA and quantified the frequency
of fire occurring on SRA trains and compared this to UK fire frequency data. The report
studied the Maidenhead rail accident in the UK and the Brighton accident in Canada to
provide background information.
The intention of the study was to carry out an assessment of the risks of fire occurring on
an SRA passenger train.
The findings of this report included that the risk of fire was higher on the SRA network
than on the UK network. The report made a calculation of fire frequency rates using the
SRA data and compared this to UK data. Dividing the number of fires occurring per annum
by the total average train kilometres per annum, it was found that the SRA fire frequency
figure was twice as high as the UK figure.
The report them made several recommendations based upon good practice established in
the UK and in Canada. One of these recommendations included:
“The provision of a facility to open the doors from the inside in an emergency is
recommended. If secondary door locking is installed then information should be provided
to passengers as to how to override it in an emergency”.
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11.0 SUMMARY
According to the accident and incident RIC/RailCorp database there were a number of
injuries and fatalities in the early to mid 1990s due to people opening doors and jumping
or alighting from moving trains. The State Rail Authority had to take action to prevent
that level of injury continuing so they introduced a door security policy. This entailed the
introduction of central locking to keep the doors locked whilst the train was in motion and
the removal or deactivation of internal door opening devices.
Although the action of locking the doors resulted in a decline in the number of injuries, a
consequence of this action was the ability of passengers to self evacuate in an emergency
was removed. There is no evidence to indicate that the decision to implement a door security
policy and remove the door opening mechanisms for passengers was based on a proper risk
assessment.
Other countries studied in this project afford passengers the capability to self evacuate
from a train in an emergency. In some countries it is mandatory that there be door opening
devices fitted for passengers to self evacuate. In fact, recent accidents highlight that it is not
enough to have the ability to open doors and windows in the event of an emergency but
that the equipment must be maintained to ensure it will work, the equipment must be able
to be used easily without the use of tools, the action of operating such equipment must pose
no extraordinary difficulty for the average person and there needs to be sufficient signage or
instructions to ensure passengers understand how to operate the equipment.
Several accidents are reviewed in this report. Some of the accidents that involved fire resulted
in fatalities when passengers were unable to escape due to locked doors, faulty equipment or
the inability to find and active emergency door release devices quickly enough.
There are examples of rail accidents where the emergency services have been unable to access
the train due to lack of familiarity regarding emergency door opening devices coupled with
inadequate signage external to the train and/or faulty door opening devices. In some cases
this delay has led to the death of some passengers. There are examples of train accidents
within NSW where the emergency services did not know how to open the train doors
and were delayed in gaining access to the train and allowing passengers out, two notable
examples being the accidents at Waterfall and at Linden-Woodford.
Within NSW, passenger trains operated by RailCorp have external emergency door release
(EDR) mechanisms installed to facilitate entry by the emergency services. These are located
behind a panel on both sides of each car. In some cases these devices require the use of
a key. There is no clear sign that directs emergency services personnel to the location and
the purpose of this mechanism, rather the acronym “EDR” is used, located on a placard
either above or adjacent to the device. This lack of identification is intended to discourage
unauthorised access to the train.
After considering rail accidents that have occurred overseas and within Australia, this project
has determined that firstly, members of the public should be afforded the opportunity to
escape from a train in extreme circumstances. Secondly, that external emergency door release
mechanisms should be clearly identified to facilitate quick activation by the emergency
responders and that their use should not require the use of any key.
In recommending the installation or reactivation of door opening devices the associated
risks must be recognised and adequate protection put in place. Door opening devices must
be designed to prevent accidental opening or deliberate misuse. It is appreciated that the
danger of vandalism to trains does exist, but this should not override the protection of
passengers.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
41
A recent tragedy in the Sydney suburb of Matraville (Sydney Morning Herald, 8 June
2004), where a woman and her two children died in a house fire, highlights the dangers that
can occur when the fear of crime overcomes the requirement of safety. To prevent burglary
the house was fitted with deadlocks, so when the fire started the occupants were locked in
the house unable to escape the flames.
Apart from the risk of passengers falling or jumping from moving trains, the other risk of
fitting emergency door opening devices is that of passengers self evacuating into what may
be a dangerous environment. For example, the hazards associated with oncoming trains
and from electrical wires. This is a legitimate concern and it is the reason that the preferred
option is most certainly for passengers to remain on the train and be evacuated under crew
control when it has been established that it is safe to do so.
However in an extreme emergency, where to remain on the train would pose the greater
threat and passengers need to evacuate, the rail operator’s emergency procedures should
provide for the quick and efficient establishment of as safe an environment as is reasonably
possible.
The subject of poor crew performance following an accident and limited training is an issue
that surfaces repeatedly in accident reports. Generally crews were found to be ill prepared
for an emergency situation. Crew emergency procedures must be effective and crew must
be adequately trained if they are to effectively manage an emergency situation. Each crew
member should have an emergency checklist located in their work area that is prominently
displayed. These procedures must be practised to ensure crew are competent. If passengers
are to follow directions from the crew they must have confidence in them. Crew must be
adequately trained so that they can effectively manage an emergency situation and instil
confidence in the passengers so that they will comply with the crew instructions. This
training should not be limited to just the driver and the guard but to all crew working on a
train, including passenger service staff and security officers, as evidenced by the accident at
Linden-Woodford.
An issue that will need further investigation is the issue of fire ratings of different train
types. In NSW there have been few fires on trains that would have posed a danger to
passengers similar to that experienced by some of the overseas operators. The majority of
fires on NSW trains are class “A” fires started by vandals using waste paper and are easily
extinguished. Materials used within passenger carriages are unlikely to burn easily.
However, one hazard that has changed in only recent times is the threat of terrorism. Until
recently Australia has been in the enviable position of being well isolated from the terrorist
threat. However, it may well be that recent world events have, to an extent which is still
unclear, increased the risk. The events in Madrid in March this year provide an example of
the disastrous repercussions of such an attack. Fire is not the only threat as terrorism can
take many other forms.
So although it may be argued that the event of a catastrophic fire is low, there are potential
situations that could arise that would require the speedy evacuation of a train. It must also
be recognised that the crew, positioned as they are at the front and often, depending on the
number of cars, the rear of the train, can be vulnerable to injury and may be unable for a
variety of reasons to conduct an evacuation. Passengers must be given an alternative.
The research for this project illustrates that passengers need to be able to escape from a train
in extreme circumstance when the situation is serious enough that to remain on the train
would pose a greater threat.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
12.0 RECOMMENDATIONS
In light of reviewed accident reports and the standards in place in other developed countries,
it is the recommendation of the project team that passengers should have the means to
escape a train of their own accord if the situation is serious enough to warrant it. This
will entail the installation of emergency door opening devices. The risks associated with
vandalism and passengers escaping into an unsafe environment are recognised and should
be taken into account when implementing this recommendation.
It is recommended that external emergency door release mechanisms should be accessible
without the use of a key and clearly identified. The abbreviation “EDR” is not recognised
by all members of the emergency services and it would be virtually impossible to train
all personnel. The issue of emergency responders being delayed in accessing the train is a
reoccurring theme throughout several of the accident reports.
To prevent unauthorised access to the train when it is stabled, the train should be locked
so that it is secure and the emergency door release mechanism rendered inoperative. The
locking system should be designed in such a way that it is impossible to move the train while
the release mechanism remains inoperative, i.e. it should not depend on crew remembering
to reactivate the release mechanism.
In recommending that the facility should exist for passengers to open doors, the possibility
of vandalism and inappropriate use of the door opening device must be recognised. There
are very real dangers associated with passengers opening doors when the train is moving,
as well as that of escaping onto nearby tracks where there is the hazard posed by oncoming
trains. As a result the following parameters should be incorporated into the installation of
door opening devices:
a) The doors should be locked when the train is moving. The doors should lock
automatically when the train is about to commence to move. This will guard against
people opening doors and falling out when the train is moving.
b) When the train comes to a stop (away from a station), for any non-emergency
situation, the train crew should be able to ensure the doors remain locked.
Passengers must not be able to detrain themselves in such a situation. Should a
passenger attempt to operate a door this action should alert the train crew, most
probably via the use of an alarm. The crew can then actively “re-lock” the door.
However this re-locking should only apply for a period of time, after which it
would need to be reactivated if still desired. There should be some signal to the
crew that the time has arrived for a decision as to whether to reactivate the locks,
otherwise, crew who are busy with other duties might overlook the situation. After
a predetermined interval of time, failure to reactivate the locks will leave passengers
free to detrain.3
c) The emergency door opening device located in the carriages must be designed and
positioned such that it cannot be operated accidentally.
d) The emergency door opening device should be guarded in such a way that it will
discourage as far as possible acts of vandalism. There must be some type of cover or
barrier over the device and it would be possible for the device to be alarmed so if it
is tampered with, the train crew would be alerted.
3
Reactivation should be an option available to either the driver or the guard because there may be a
situation where one member of the crew is required to leave the train, such as when track protection has
to be achieved.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
43
e) There should be a suitable penalty imposed for those persons found guilty of
tampering with safety equipment and/or emergency door opening devices. This is
a crime of a different nature from that associated with acts of vandalism such as
graffiti, rather this is a crime that endangers public safety.
f ) Train crew emergency procedures and training will need to be reviewed to
encompass any new equipment and procedures that result from a change to door
policy.
To support the installation of door emergency opening devices, it is recommended that the
following plans, procedures and infrastructure be put in place:
g) The placement of signage regarding emergency evacuation and escape needs
research and consideration. The Australian Standard for safety signage should be
adhered to when developing emergency signs for the inside of the carriages. The
placement of information in seat pockets, on the back of seats, at emergency exits
or on tickets, all needs to be reviewed. This review must take into account any
differences between metropolitan and country operations.
h) The installation of additional safety equipment needs to be reviewed; the reviewed
accident reports frequently refer to the benefit of placing equipment such as torches
and loudhailers on board.
i) There needs to be an investigation into the ability of the PA system, the emergency
lighting and the emergency door opening operation to continue in the event of
the loss of power. Many accident reports mention the failure of the PA system
and inadequate emergency lighting. This should be reviewed to ensure the system
works when power is lost.
j) The facility for communications between the passengers and the train crew and
the facility for communication between the passengers and train control or other
location external to the train needs further investigation.
k) The ability to operate internal doors (i.e. those that facilitate passage between cars)
when the cars are on their sides needs further investigation.
l) The ability to open doors from both the inside and the outside, when the train is on
its side, needs further investigation.
The self evacuation of passengers from a train involved in an emergency is a last resort. It
is emphasised that the first preference following an emergency would be for a controlled
evacuation that is managed by the train crew. The train crew would be responsible for
unlocking the doors to be used for the evacuation, they would then conduct a controlled
evacuation and direct and assist all passengers to a place of safety, well away from the
dangers of electrical overhead wires and railway tracks. To support the crew in this role,
the following recommendations are made to ensure they are best equipped to handle any
emergency situation:
m) Crew emergency plans and procedures should be rewritten to ensure they are clear
and effective. Checklists for crew members should be developed from these plans.
These checklists should be positioned within the crew work area so they can be
readily referred to and actioned in the event of an emergency.
n) All train crew will need to be trained in emergency procedures, including
evacuation procedures to ensure they can respond effectively. This training should
be conducted on a regular basis, for example annually, to ensure skills are refreshed
and kept up to date. This training should involve all staff who work onboard the
train, including passenger service staff and security officers.
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
o) As part of their emergency procedures, train crew should receive training in the use
of the PA in an emergency and they must have the opportunity to practise making
emergency announcements during training. These skills should be assessed and
crew should achieve a satisfactory standard.
To ensure the safety of passengers following an evacuation, rail operators need to have in
place an effective emergency response plan that will enable quick recognition and response
to an emergency situation. These plans and their supporting procedures must ensure the
following:
p) Quick recognition of an emergency occurrence, including location, detail of the
equipment involved and other relevant information;
q) Activation of the operator’s emergency procedures to ensure appropriate
notification of personnel;
r) Notification to the emergency services with timely and accurate information;
s) Activation of the appropriate emergency procedures to make the area within the
vicinity of the accident “safe” especially with respect to advising and stopping of
oncoming trains and the removal of electrical power.;
t) Despatch of appropriate personnel to the site.
It must be taken into account in all of the above points that inherent differences in
equipment and procedures between train operations within NSW need to be identified
and catered for. For example metropolitan train operations and operations within tunnels
may present different issues from long distance intercity or interstate travel and the historic
tourist rail operators may face different issues again. Due to the differences in equipment
and in operating environments, these operators and their passengers face different risks.
When imposing standards across a range of operators, there must be enough flexibility to
allow for these differences to ensure the safety of the travelling public. These different types
of operations need recognition and consideration.
ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
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13.0 REFERENCES
ATOC Vehicles Standard AV/ST9002, Vehicle Interiors Design for Evacuation and Fire
Safety. Issue One, December 2002. Published on behalf of Association of Train Operating
Companies (ATOC) by Railway Safety, London.
APTA SS-PS-002-98 Rev 1. Standard for Emergency Signage for Egress/Access of Passenger
Rail Equipment. The American Public Transport Association, Washington D.C. Approved
March 4, 1999.
APTA SS-PS-003-98. Standard for Emergency Evacuation Units for Passenger Rail Cars.
The American Public Transport Association, Washington D.C. Approved June 15, 1998.
British Standard, BS 6853:1999. Code of practice for fire precautions in the design and
construction of passenger carrying trains. British Standards Institute. 4 December 2002.
“Collision and Derailment of Maryland Rail Commuter MARC train 286 and National
Railroad Passenger Corporation AMTRAK train No. 29 near Silver Spring, Maryland
on February 16, 1996,” Railroad accident report, NTSB/RAR-97/02, Washington DC,
1997.
Cullen, The Rt Hon, The Ladbroke Grove Rail Inquiry Part 1, HSE Books 2001,
ISBN 0 7176 2056 5.
“Derailment of AMTRAK train No.2 on the CSXT Big Bayou Canot Bridge near Mobile,
Alabama September 22, 1993.” Synopsis of Railroad-Marine accident report, NTSB RAR94/01. Washington DC, 1994.
“Derailment. Canadian National Train No. 698, Ontario Northland Railway.” 31 March
1996. Report Number R96T0111. Transportation Safety Board of Canada.
“Derailment. VIA Rail Canada Inc.” Near Biggar, Saskatchewan. 3 September 1997.
Railway Occurrence Report R97H0009. Transportation Safety Board of Canada.
Det Norske Veritas (1999) Passenger Train Fire Risk Assessment for State Rail Authority
DNV3653.
Early Response System and Improvement of Fire Safety Performance in the Dae-gu Subway
Disaster. Authors: Sam-Kew Roh Professor, Jun-Ho Hur, Jong Hoon Kim, Woon Hyung
Kim Professor, Kwangwoon University, Seoul, Korea.
Emergency Order No. 20. US Department of Transportation, Federal Railroad
Administration. Issued in Washington D.C. on February 20, 1996.
Evacuating an Overturned Smoke Filled Rail Carriage, Authors: E R Galea and S Gwynne,
Paper No 00/IM/55, ISBN 1899991 56 5, CMS PRESS, 2000.
Federal Railroad Administration (FRA), U.S. Department of Transportation, Code of
Federal Regulations (CFR), Title 49, Volume 4. Chapter 11. Revised October 1, 2003.
Part 238 Passenger Equipment Safety Standards.
Federal Railroad Administration (FRA), Department of Transportation, Code of Federal
Regulations (CFR), Title 49, Volume 4. Chapter 11. Revised October 1, 2003. Part 239
Passenger Train Emergency Preparedness.
“Fire - VIA Rail Canada Inc. VIA Passenger Train struck a piece of rail placed on the track.”
Brighton, Ontario. 20 November 1994. Report Number R94T0357. Transportation Safety
Board of Canada.
“How could it have happened?” Report on the fire on the Kaprun funicular railway, Austria.
11 November 2000. BBC News. http://news.bbc.co.uk
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ITSRR Report: Train door emergency egress and access and emergency evacuation procedures
“Norway crash toll reaches 19.” Report on collision near Asta, Norway. 8 January 2000. BBC
News. http://news.bbc.co.uk
“Public Crossing Accident. VIA Rail Canada Inc.” Riviere-Beaudette, Quebec. 04
November 1994. Report Number R94D0191. Transportation Safety Board of Canada.
Railway Group Standard, Emergency and Safety Equipment and Signs on Rail Vehicles. GM/
RT 2177. Issue one. January 1995.
Railway Group Standard, Power Operated External Doors on Passenger Carrying Rail Vehicles
GM/RT 2473. Issue one. February 2003.
Railway Passenger Car Inspection and Safety Rules. The Railway Association of Canada.
TC number 0-26. Date of revision Nov. 8th, 2001.
Railway Passenger Handling Safety Rules. The Railway Association of Canada. TC
number 0-16. Approved March 31st, 2000.
Railway Research Project No. 6 – “Research into Emergency Door Release”. Interfleet
Technology, Author: Wendy Gamble. Report No. ITLR-T11271-005. 31 January 2003.
Railway Safety Investigation Report on the Rail Accident at Waterfall, NSW, Australia. 31
January 2003. NSW Ministry of Transport.
Report on the Derailment and Collision involving ballast train M520 and passenger train
SN53 at Bargo-Yerrinbool, NSW, Australia. 1 August 2002. Transport Safety Bureau.
Transport NSW.
Report on the Interurban Train Incident Linden-Woodford, NSW, Australia. 25 July 2000.
Transport Safety Bureau. New South Wales Department of Transport.
Report on the Passenger Train Collision with a Derailed Coal Train at Hexham, NSW,
Australia. 12 July 2002. Transport Safety Bureau. Transport NSW.
Report on the Suburban Train Derailment at Kingsgrove, NSW, Australia. 6 October
2000. Transport Safety Bureau. New South Wales Department of Transport.
Uff, Professor John, The Southall Rail Accident Inquiry Report.
ISBN 0 7176 1757 2.
HSE Books 2000,
“Waterfall Rail Accident.” Special Commission of Inquiry. Transcript of Inquiry Hearings,
Day 84, evidence of Mr Heumiller.
“Waterfall Rail Accident.” Special Commission of Inquiry. Transcript of Inquiry Hearings,
Day 11, evidence of Mr Frankovic.
“Waterfall Rail Accident.” Special Commission of Inquiry. Transcript of Inquiry Hearings,
Day 24, evidence of Mr Johnson.
“Waterfall Rail Accident.” Special Commission of Inquiry. Transcript of Inquiry Hearings,
Day 62, evidence of Mr Lauby.
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